Breast cancer in elderly women: presentation, survival, and treatment options

Breast cancer treatment in the elderly: Do treatment plans that do not conform to NCCN recommendations lead to worse outcomes?

BACKGROUND

Aging remains one of the greatest risk factors for development of new breast cancer with more than 30% of breast cancers occurring after the age of 75. Elderly women have been found to not conform with all aspects of treatment recommendations. Our study compared outcomes of elderly breast cancer patients whose treatment did or did not conform to NCCN guidelines.

METHODS

A retrospective review was conducted of breast cancer patients over the age of 70. Comparisons were made between patients whose treatment did or did not conform to NCCN guidelines for recurrence, metastatic disease, and breast cancer related deaths.

RESULTS

Patients whose treatment did not conform to NCCN guidelines were older (80.5 vs. 77.7 years, P = 0.001). No significant difference was seen between groups for tumor size, breast cancer type, or nodal status; however, more nonconforming women were ER/PR positive (90.3% vs. 76.6%, P = 0.020). There was no significant difference in local recurrence, metastatic disease, or breast cancer related deaths.

CONCLUSIONS

Women whose treatment did not conform to NCCN guidelines were not associated with worse outcomes.

Locally Advanced Breast Cancer in the Elderly: Curettage Mastectomy

Aims and background

Locally advanced breast tumor represents 5–20% of new cases diagnosed every year. The purpose of this study was to report our experience and to compare it with the literature.

Methods

From 1998 to 2003 at the Molinette Hospital in the Turin University Third Division of General Surgery, there were 34 cases of breast cancer in older women (between 70 and 94 years of age), 14 of which (41.18%) were locally advanced breast tumor. We evaluated the type of surgical intervention and anesthesia used, muscular invasion, the presence of receptors positive to estrogens and progesterone, the operative mortality, the percentage of local-regional recurrence, and relapses after a period of time.

Results

Among the patients with locally advanced breast tumor, 21.43% (3/14) were at stage MIA and 78.57% (11/14) at stage IIIB. In 14.29% (2/14) of the cases, Patey's radical mastectomy was performed, in 57.14% (8/14) Halsted's radical mastectomy, and in 28.57% (4/14) a simple mastectomy with the removal of the fascia of the major pectoral muscle. Three (21.43%) patients underwent a second intervention for local-regional disease. None of the patients had distant metastasis in the first 2 years after the operation. Mortality after 2 years was 23.1% (3/13). None of the patients who underwent surgery had adjuvant therapy, usually because it was refused by the patients themselves or their families. All the negative and positive hormone receptor patients received tamoxifen.

Conclusions

Locally advanced breast tumors are frequent in elderly women. In the past, there has been a tendency to surgical under-treatment. As regards locally advanced breast tumor, curettage operations represent the only possibility to improve the quality of life of the elderly. These should be performed after carefully evaluating a series of variables in the general and local condition of the patient, the aggressiveness of the intervention and the life expectancy.

Locally Advanced Breast Cancer in the Elderly: A Major Challenge Requiring Effective and Appropriate Treatment

Aims and background

Breast cancer is the most common tumor in women. As the population above 65 years increases, breast cancer will be a more substantial problem for elderly patients. This work reports our experience in the management of stage III and IV locally advanced breast cancer.

Methods

Nineteen patients over 65 years of age (mean, 70.3 years) with stage III and IV breast cancers, treated between 1990 and 2000, are considered. The management and outcome are evaluated.

Results

Nine patients had stage IIIA breast cancer, 7 stage IIIB and 3 stage IV. Sixteen underwent Madden mastectomy and 3 simple mastectomy. Patients at stage HIB and 1 patient at stage IV with T4 tumor received neo-adjuvant chemotherapy. There were no significant postoperative complications. Sixteen patients were given tamoxifen and 10 patients adjuvant chemotherapy. Patients were followed for a median of 36.7 months (range, 6–72 months). In 8 patients with stage III disease, metastasis developed. Two patients had local recurrence of disease. Of the patients at stage IIIA, 6 were free from disease (one died from unrelated causes) and 3 had recurrent disease (2 died). Of the patients at stage IIIB, 2 are disease free and 5 had recurrent disease and died. Of the patients at stage IV, only one is alive.

Conclusions

Stage and individual characteristics of elderly women influence management. Patients should be managed adequately since most of them are fit enough to undergo treatment.

Octogenarians: Noncompliance with Breast Cancer Treatment Recommendations

Recent research suggests that women older than 70 years of age with early breast cancer who choose lumpectomy may forgo radiation if they take antihormonal medication. However, many elderly patients choose to forgo both radiation and hormonal therapy. This study assessed treatment compliance in elderly patients with breast cancer. A retrospective review was conducted of patients with new-onset breast cancer older than 70 years of age. Patients were stratified by age (70 to 79 vs 80 years or older) and surgical procedure (lumpectomy vs mastectomy). Ninety-seven patients were included; 47 were aged 70 to 79 years, whereas 50 were aged 80 years or older. Treatment recommendations were similar between age groups; however, patients aged 80 years or older were more often noncompliant with recommendations for surgery (14.9 vs 0.0%, P = 0.012), radiation therapy (64.0 vs 16.0%, P = 0.001), and hormonal therapy (53.3 vs 22.6%, P = 0.013). When stratified according to surgical procedure, women aged 80 years or older receiving lumpectomy were overall more noncompliant (50.0 vs 14.8%, P = 0.014) than younger women. Women older than 80 years of age who elected for lumpectomy treatment were significantly less likely to receive standard recommendations of adjuvant hormonal or radiation therapy. The reasons for this vary and it is unknown whether this impacts their local recurrence or survival rate.

Assessment of Surgical Treatment in Elderly Patients with Breast Cancer

Aims and Background

The incidence of breast cancer increases with advancing age and in clinical practice approximately 50% of new cases occur in women over the age of 65 years. Although breast cancer in elderly patients presents more favorable biological characteristics than similar-stage cancer in younger women, disease control still remains uncertain and is becoming a major health problem.

Patients and Methods

Between 1984 and 2006, 133 patients aged over 65 with operable breast cancer underwent surgical treatment. Patients with ductal or lobular carcinoma in situ, bilateral breast cancer or a previous malignancy were excluded. The mean age was 72.8 years (range, 66–89). Breast-conserving surgery was performed in patients with early breast cancer (T1, T2 <2.5 cm), while most patients with advanced tumors (T2 >2.5 cm, T3, T4) were treated by modified radical mastectomy.

Results

The pathological stage was I in 44, IIA in 54, IIB in 18, IIIA in 10 and IIIB in 7 patients. Postoperative complications occurred in 13 patients (9%); there were no postoperative deaths. Eighty-nine patients underwent adjuvant therapy (chemotherapy, hormonal therapy). After a median follow-up of 96 months (range, 5–266), disease progression was observed in 21 patients (15.8%). The overall mortality from breast cancer was 11%, whereas the cancer-unrelated mortality was 9%.

Conclusion

There is no evidence that breast cancer has a more favorable prognosis in the elderly and surgical procedures should be carried out as has been established in younger women. At present, elderly patients are much less likely to be entered into randomized clinical trials and are often undertreated. However, in the absence of serious comorbid disease, they are able to withstand standard multimodal treatment options as well as do younger patients.

Conservative management of breast cancer in the elderly in a developing country

Background

The cost effective treatment of cancer in developing countries remains challenging. In the elderly with possible limited life expectancy, the health expenditure associated with standard treatment regimes should be carefully considered. We present the results of conservative management of breast cancer in the aged in a resource-limited environment.

Methods

Patients aged 70 or older with early breast cancer were treated with tumour excision or simple mastectomy and adjuvant tamoxifen. The records of patients presenting to the Breast Unit between January 1990 and December 2004 were retrieved and demographic, clinical, pathological and oncological data were reviewed. Survival statistics were calculated using the life table method.

Results

A total of 483 patients above 70 years of age were identified. One hundred and eighty eight patients were managed according to the conservative protocol. Forty-one had a simple mastectomy and 147 tumour excision. Their mean age was 77.3 years. The mean follow-up is 62 months. Thirty-one patients (16.4%) were not compliant with tamoxifen use. TNM staging was 0 in 4 patients, I in 42 patients, II in 116 patients and III in 26 patients. There was no 30-day mortality. The cumulative incidence of local recurrence was 3.3% at 5 and 10 years. The cumulative incidence of regional recurrence was 3.3% at 5 years and 4.5% at 10 years. The cumulative incidence of distant recurrence was 6.2% at 5 years and 12.2% at 10 years. The cumulative overall, disease specific and disease free survival at 10 years was 59%, 88% and 81% respectively.

Conclusion

Limited surgery and tamoxifen provide excellent control of breast cancer in the elderly in a resource restricted environment. Radiotherapy and axillary dissection and can be safely omitted thereby reducing health care resource utilization.

Common Gynecologic Problems in Geriatric-aged Women

Gynecologic concerns in postmenopausal women are common. Although various conditions may affect all women in this age group, the prevalence of certain disorders, and also diagnostic approaches and treatment options, may vary significantly when considering very elderly women compared with those early in the sixth decade. The focus of this chapter is to address several commonly encountered gynecologic issues in postmenopausal women, with particular attention given to aspects that must be considered when caring for women in the geriatric age group.

Association of late childbearing with healthy longevity among the oldest-old in China

Statistical analysis of a large and unique longitudinal data-set demonstrates that childbearing after age 35 or 40 is associated with survival and healthy survival among very old Chinese women and men. The association is stronger for women than for men. The estimates are adjusted for a variety of confounding factors: demographic characteristics, family support, social connections, health practices, and health conditions. Further analysis based on an extension of the Fixed-Attributes Dynamics method shows that late childbearing is positively associated with long-term survival and healthy survival from ages 80-85 to 90-95 and 100-105. This association exists among oldest-old women and men, but, again, the effects are substantially stronger for women than for men. We discuss four possible factors that may explain why late childbearing affects healthy longevity at advanced ages: (1) social factors; (2) biological changes caused by late pregnancy and delivery; (3) genetic and other biological characteristics; and (4) selection.

Quality of life in breast cancer patients aged over 70 years, participating in the EORTC 10850 randomised clinical trial

Mastectomy and breast-conserving treatment have proven equally effective in terms of survival in early breast cancer, but studies continue to provide evidence that patients undergoing breast-conserving procedures have a better quality of life (QOL). Age is not considered to be a contraindication for breast-conserving treatment, but retrospective studies have indicated that elderly patients are less likely to be treated conservatively. In the present study, survival, QOL and treatment preference have been investigated in a multicentre, randomised clinical trial of elderly patients with early breast cancer undergoing mastectomy or tumour excision plus tamoxifen. Eligible patients were aged 70 years or more and had histologically- or cytologically-confirmed operable breast cancer. A QOL questionnaire consisting of 36 items was constructed covering 9 scales assessing different QOL domains. Patients completed their assessment between 2 and 12 months after randomisation. 136 patients (65 in the mastectomy arm and 71 in the local excision arm) from six centres filled out a QOL form during the first year of follow-up. No significant difference in the duration of survival between the two treatment arms was observed when including patients included in the QOL sub-study (P=0.33). Patients undergoing tumour excision and tamoxifen did not differ from those undergoing mastectomy in terms of fatigue, emotional functioning, fear of recurrence, social support, physical functioning and leisure time activities. However, conservatively treated patients reported fewer arm problems (P=0.04) and a shift, although borderline significant, in the direction of a benefit in body image (P=0.06). As QOL seems to be better after conservative treatment, such treatment is to be preferred in both elderly and younger patients.

Optimal Management of Primary Breast Cancer

The diagnosis and treatment of breast cancer have changed in response to not only new technologies but also cultural and social aspects of the disease. While breast-conserving surgery and adjuvant therapy are the preferred treatments for many breast cancers, neoadjuvant therapy is often used in advanced disease. In this review we examine the treatment options that are influenced by pathologic and clinical factors. Invasive breast cancer is a potentially curable disease if it is regarded and managed by a multidisciplinary approach from the outset.

Surgical management of breast cancer in the elderly patient

BACKGROUND

Breast cancer in the older woman is a major health issue and therapeutic challenge. This study asked if presentation, surgical treatment, and outcome of breast cancer are different in elderly women compared with their younger counterparts.

METHODS

There were 816 women < 70 years (younger) and 190 > or = 70 years (older) treated surgically for breast carcinoma between January 1992 and April 2000. Data for younger and older patients was analyzed from our prospective database.

RESULTS

More older women had mammographic lesions (P < 0.006). Breast conservation was the treatment of choice for both groups. Stage, tumor size, histology and disease-specific survival were similar for both. There was no evidence of disease in 93% of cases in the < 70 years group at median follow-up of 38.4 months and 91% for the > or = 70 years group at 44.5 months.

CONCLUSIONS

In our population the presentation, surgical treatment, and survival from breast cancer is similar in older and younger women.

Breast conservation therapy as a treatment option for the elderly. The M. D. Anderson experience

BACKGROUND

Although almost half of all incidents of breast carcinoma occur in women age > or = 65 years, not enough is known about appropriate care for patients in this age group. The objective of the current study was to evaluate the role of breast conservation therapy in the management of breast carcinoma in women age > or = 65 years.

METHODS

From 1970 to 1994, 1325 patients with carcinoma of the breast were treated with breast conservation therapy (segmental mastectomy and radiation therapy with or without axillary lymph node dissection) at The University of Texas M. D. Anderson Cancer Center. From this patient group, the authors identified 184 elderly women (> or = 65 years) with Stage 0-III disease at the time of diagnosis.

RESULTS

The median patient age was 70 years (range, 65-88 years). The distribution of disease by stage among the women was Stage 0 disease in 12 patients (7%), Stage I disease in 107 patients (58%), Stage II disease in 63 patients (34%), and Stage III disease in 2 patients (1%). Comorbid conditions that may have influenced treatment planning were reported in 91 patients (50%). An axillary lymph node dissection was performed in 135 patients (73%), with positive axillary lymph nodes found in 30 patients (22%). Adjuvant chemotherapy was given to 10 patients (5%), and tamoxifen therapy was given to 63 patients (34%). Complications from treatment were reported in 24 patients (13%). With a median follow-up of 7.3 years (range, 0.25-23.5 years), 9 patients developed locoregional disease recurrence (5%), 10 patients developed contralateral breast carcinoma (5%), and 21 patients developed distant metastasis (11%). At last follow-up, 113 patients (61%) were alive, 15 patients (8%) were dead of disease, and 56 patients (30%) were dead of other causes. The 5-year and 10-year disease specific survival rates were 96% and 91%, respectively.

CONCLUSIONS

Breast conservation therapy with segmental mastectomy and postoperative radiation therapy with or without axillary lymph node dissection provides excellent local control and disease free survival in elderly women with breast carcinoma. This treatment should be considered as the standard of care for elderly patients without severe comorbid disease.

Preoperative endocrine therapy for older women with breast cancer: renewed interest in an old idea

BACKGROUND

Tamoxifen as sole therapy (primary tamoxifen therapy) was investigated in the 1970s and 1980s as an alternative to surgery for older patients with breast cancer. While the majority of primary breast tumors responded to tamoxifen, long-term local disease control was poor. The use of primary tamoxifen therapy is therefore restricted to frail, elderly, and infirm patients who cannot tolerate surgery. In contrast, short-term preoperative endocrine therapy to downstage estrogen receptor-positive (ER+) tumors is under increasing scrutiny as a nontoxic neoadjuvant approach for older women.

METHODS

The literature on primary tamoxifen therapy and preoperative endocrine therapy was reviewed to construct an opinion piece on the feasibility and safety of preoperative endocrine therapy.

RESULTS

A review of nine phase II trials and a meta-analysis of two randomized trials suggest that the initial response rates to preoperative endocrine therapy will exceed 50% to 60% for patients with ER+ disease. A short delay in surgery to administer 3 to 4 months of preoperative endocrine therapy is unlikely to compromise long-term outcomes.

CONCLUSIONS

Preoperative endocrine therapy is a logical approach for older patients with ER+ disease as a well-tolerated means to increase the rate of breast-conserving surgery. Several clinical trials comparing tamoxifen with selective aromatase inhibitors in the preoperative setting have been conducted, and the results are expected soon. These studies will determine if a large multicenter national trial of preoperative endocrine therapy should be conducted.

Cancer screening in the elderly population

This article reviews the current state of knowledge regarding cancer screening in the geriatric population. Care of the elderly requires knowledge of underlying physiologic changes, comorbidities, quality-of-life factors, and life expectancies. There is always the danger that ageism may prevent elderly cancer patients from receiving the proper treatment. On the other hand, overzealous treatment can lead to adverse results if elderly patients are not properly targeted based on current evidence of the benefits and risks of specific screening practices.

Time trends in systemic adjuvant treatment for node-negative breast cancer

PURPOSE

We conducted a population-based study in Quebec, Canada, to assess longitudinal changes in systemic adjuvant therapy for node-negative breast cancer.

MATERIALS AND METHODS

A stratified random sample was selected among women with newly diagnosed node-negative breast cancer in 1988, 1991, and 1993. Information on the patient, her tumor, source of care, and treatment was abstracted from medical charts. Patients were classified as being at minimal, moderate, or high risk of recurrence on the basis of criteria proposed at the 4th International Conference on Adjuvant Therapy of Primary Breast Cancer (St. Gallen, Switzerland, 1992), and systemic adjuvant treatment received was dichotomized as being consistent or not consistent with consensus recommendations.

RESULTS

Overall, 1,578 cases of invasive breast carcinoma were reviewed. The proportion of patients who were given hormonal or cytotoxic treatment increased from 51.7% to 73.1% from 1988 to 1993. Virtually all women at minimal risk were treated in 1991 and 1993 according to the consensus statement. The proportions of women so treated were 75.0% and 65.4% in the moderate- and high-risk categories, respectively, in 1991. In 1993, these proportions were 71.4% and 67.0%, respectively. Omission of chemotherapy, especially in high-risk women with estrogen receptor-negative tumors who were 50 to 69 years of age, was the most frequent inconsistency with guidelines.

CONCLUSION

Systemic adjuvant therapy for node-negative breast cancer has gained acceptance. Better understanding of the decision-making process, of the perception of the risks and benefits involved, and of the impact of alternative strategies for the dissemination of consensus recommendations are needed to promote the use of chemotherapy in specific categories of women who are at high risk of recurrence.